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HealthPayerIntelligence News

How Do Medicare Advantage, Medicare Supplemental Insurance Differ?

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Medicare Advantage (MA) and Medicare supplemental insurance, or Medigap, are both intended to enhance the value of traditional Medicare coverage for seniors and other eligible beneficiaries. Both offer payers a lucrative opportunity to meet...For example, Medigap policies for Part A can help beneficiaries cover 100 percent of their hospital coinsurance costs. Supplemental insurance plans are divided into categories with an alphabetic label.  Medigap plans in tiers A through...

Pros and Cons of Small Business Health Options Program Health Plans

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Health plans offered through the Small Business Health Options Program (SHOP) exchanges allow payers to provide the nation’s smallest businesses with affordable plan options that offer critical health benefits. SHOP health plans opera...

Emergency Physician Group Sues Anthem for ED Payment Policies

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The American College of Emergency Physicians (ACEP) and the Medical Association of Georgia (MAG) have filed a lawsuit against Anthem BCBS of Georgia contesting an emergency department payment policy that makes patients responsible for cover...

All-Payers Claims Databases May Increase Healthcare Price Transparency

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Leveraging the data of all-payers claims databases (APCDs) could improve healthcare price transparency for consumers, according to testimony presented at a House Energy and Commerce Committee hearing. Jamie S. King, a professor at the USC H...

High Dollar Claims Rise by 87% in Employer-Sponsored Stop-Loss Insurance

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The number of employer-sponsored stop-loss insurance claims of $1 million or more grew by 87 percent from 2014 to 2017, according to a new analysis from Sun Life Financial. Over the four-year period, 634 employees with $1 million claims cos...The top five most expensive treatments were mainly for blood diseases. The most expensive drug on the list was Yervoy, a cancer treatment. Large employers are more likely to have a higher number of high claims costs than smaller employers. ...The likelihood of an employer filing a stop-loss claim for cancer related tumors is 50.7 percent, meaning that payers sponsoring stop-loss insurance will likely have to cover some form of cancer care for half of their employer clients. Addi...

How Payers Can Succeed Under Updated 2019 HEDIS Measures

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The Healthcare Effectiveness Data and Information Set (HEDIS) provides 90 percent of America’s health plans with the ability to directly compare performance across the national stage.   Currently, the HEDIS set contains 92 measur...Some of the changes to some of the requirements around preventive care and chronic disease management for 2019 may require payers to work with their contracted providers to ensure delivery of care, while others will alter the way payers rep...

BCBSA Adds Opioid Abuse Accreditation to Treatment Facilities

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The BlueCross BlueShield Association has announced a new accreditation program for opioid abuse treatment centers as a larger part of the organization’s mission to combat the US opioid crisis. In 2013, only 22 percent of treatment fac...

CMS Proposes Drug Pricing, Price Transparency Changes for Medicare

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CMS has proposed a series of policy changes for Medicare that would promote prescription drug affordability within Medicare, and has also requested stakeholder comments about ways to improve price transparency for Medicare services. As part...

Medicare Advantage Savings, Outcomes Exceed Fee-For-Service

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The Medicare Advantage (MA) program has surpassed Medicare fee-for-service (FFS) in developing positive member healthcare outcomes and reducing care costs, according to an analysis of both programs from Avalere Health. Medicare Advantage be...Medicare Advantage has roughly 500,000 more beneficiaries than the Medicare fee-for-service program, but each program has nearly the same prevalence of chronic diseases in their populations. Both MA and Medicare FFS population have a diabet...

Health Plan Cost Sharing, Deductibles Outpace Members’ Wage Growth

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Health plan cost sharing and deductible spending have outpaced employee wage growth in the last ten years, according to data released by the Peterson-Kaiser Health System Tracker. Employees’ total financial responsibility increased by...In 2016, employees spent an average of $417 for deductibles, $249 for coinsurance, and $140 on copays. The team found that even though costs grew, employer-sponsored health plans began to cut back on spending for care costs. “Overall,...

CMS Cuts ACA Navigator Funding Grants by $26M for 2019

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CMS has announced a $26 million cut to funding grants for ACA navigators, from $36 million down to $10 million. CMS will provide a minimum of $100,000 in each of the states that operate a federally-facilitated exchange (FFE). The funding wi...

Medicare Advantage Star Ratings Tied to Member Socioeconomic Strata

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Medicare Advantage (MA) health plans with a greater proportion of socioeconomically challenged members are more likely to have lower star ratings, according to new research from Brown University. Insufficient risk adjustment criteria in the...

CMS Proposed Rule Cuts State Authority to Divert Medicaid Payments

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CMS has proposed a new rule that would eliminate a state’s authority to divert Medicaid payments away from providers. The rule is intended to ensure beneficiaries have adequate access to healthcare services through direct state-to-pro...

Transitional Health Insurance Plays Key Role in Coverage

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Transitional health insurance, otherwise known as a short-term health plan, is a temporary insurance policy intended to provide stop-gap coverage when an individual is in between ACA compliant policies.  The National Association of Ins...

CMS Suspends $10.4B in Risk Adjustment Payments to Payers

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CMS has temporarily withheld $10.4 billion in risk adjustment payments for 654 healthcare payers, citing a ruling in the US District Court of New Mexico that invalidated the agency’s risk adjustment methodology. The ruling, which took...The individual health plan market will lose nearly $7 billion in risk adjustment payments. Small group health plans in the program will miss out on nearly $2 billion in total risk adjustment payments. Catastrophic and merged market plans (w...

Vermont Government Plans Regulations for Association Health Plans

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Vermont’s Department of Financial Regulation (DFR) is planning to implement emergency rules and regulations for association health plans (AHPs) following the Department of Labor’s final rule to allow AHP sales nationally. DFR sa...

NCQA Updates, Adds HEDIS Performance Measures for Plan Year 2019

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The National Committee for Quality Assurance (NCQA) has released updates to its HEDIS performance measures for plan year 2019. The refresh includes several new measures to guide population health management initiatives, as well.   NCQA...

CMS: Individual Health Plan, Federal Exchange Challenges Remain

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CMS has released three new reports indicating that the individual health plan and federal exchange markets faltered somewhat in 2017 because of increasing premiums, decreasing competition, and stagnant enrollment. The agency believes that t...Fifty-seven percent of individual health plan enrollees in the US received a CSR for the remainder of plan year 2017. Additionally, 84 percent qualified for an APTC as well. Federal exchange consumer satisfaction increased from 2016 to 2017...

Medicare, Medicaid Home Health Benefits Stabilize Care Costs

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Providing extended home health benefits for Medicare beneficiaries is likely to stabilize care costs for public payer programs, according to a new analysis from the Commonwealth Fund. Researchers from the Hilltop Institute and Johns Hopkins...The majority of expenses in the program were for personal assistance services, which cost $216 million, or 87 percent of total program costs, in 2016. Provider monitoring and training was the second largest expense, at $24 million in 2016, ...

DOJ Nabs 601 Defendants in Biggest Healthcare Fraud Takedown Yet

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HHS Secretary Alex Azar and Attorney General Jeff Sessions have announced the largest healthcare fraud takedown yet after HHS, the Department of Justice (DOJ), and other law enforcement agencies charged 601 healthcare professionals for $2 b...

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